A patient came in with a history of breast cancer and wants her port removed. Physician did a full exam and then did the port removal. Should I code his office visit with it? Just doesn't seem like he really did anything and this looks like a level 2...

Can you post the note? We run into this and depending on the medical necessity of the E/M we would bill it and use an appropriate modifier with the port removal. But we have just removed the port(normally when they are inpatient status).

Oh boy is this one tough. My docs have documented little before on some procedures but this one seems a little too light on the documentation. From a compliance standpoint would he/she feel comfortable in an audit with Medicare? Eeeks. As for the level. I don't see any HPI elements to bill a new pt code. I would defer to the 99499 if at all anything for an E/M. Sorry not much help but this one would be going back to the provider if it was one of mine

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